Job description
Berkshire Hathaway Homestate Companies, Workers Compensation Division, has an opening for a Special Investigator to conduct investigations of suspected provider fraud referred from internal and external sources in compliance with regulatory requirements of assigned state(s). The ideal candidate will be mid-to-senior level in their career (5-10+ years of experience specializing in provider or health care fraud involving workers compensation claims, or in law enforcement, or a combination thereof) and adept in getting thoroughly vetted referrals to the Department of Insurance and applicable law enforcement and prosecutorial agencies, responding to requests for information, and providing testimony as called upon for those referrals being prosecuted.
ESSENTIAL RESPONSIBILITIES
PERFORMS INVESTIGATIONS OF SUSPECTED PROVIDER FRAUD
- Thoroughly reviews referrals from internal and external sources, investigating all indication of suspected fraud.
- Triages and logs referrals; prioritizes accordingly.
- Conducts review of publicly available and subscription-based databases and documentation to identify provider ownership, leadership, and operations.
- Recommends and executes courses of action to move investigations to resolution, including directing the work of outside investigators retained to provide investigative assistance to the Company.
- Documents all investigations thoroughly and in a manner compliant with various state Departments of Insurance and other law enforcement agencies.
- Prepares detailed reports and presentations regarding ongoing investigations, including findings and recommendations.
- Prepares and submits suspected and documented provider fraud referrals to law enforcement and prosecutorial agencies when appropriate. Responds to requests for information.
- Stays abreast of case progress and responds to any additional requests for information; If required, provides deposition and/or courtroom testimony.
ADDITIONAL RESPONSIBILITIES
- Collaborates effectively with Special Investigations Unit team members, senior management, and key internal partners (such as Medical Bill Review, Utilization Review, Claims Adjusting, and Legal) to share information and expertise, define investigative strategies and goals, and optimize the use of investigative outcomes to safeguard the company’s interests.
- Maintains expertise in workers’ compensation provider fraud, investigative techniques, and legal requirements, staying informed about new developments and current trends in these areas.
- Keeps an active caseload list and diary of assigned investigations, managing workload to maximize efficiency.
- Conducts data analyses to identify potentially fraudulent policies and emerging schemes.
- Provides testimony related to provider investigations in various legal settings.
- Supports key anti-fraud personnel in identifying red flags.
- Assists in developing and presenting annual Special Investigations Unit training required by the Department of Insurance across multiple jurisdictions, and identifies opportunities for additional training to ensure timely and quality referrals by company staff. Provides courtesy training on provider fraud related topics to external parties (such as law enforcement, industry peers, etc.).
- Identifies, establishes, and cultivates external relationships with industry contacts and law enforcement involved in fraud investigation, detection, and prevention.
- Ensures strict confidentiality of all investigations.
REQUIRED QUALIFICATIONS
- EDUCATION: Minimum of high school diploma, or equivalent certificate, required. Bachelor’s degree from an accredited four-year college or university preferred.
- DESIGNATIONS/CERTIFICATIONS: One or more preferred: Accredited Health Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Insurance Fraud Investigator (CIFI), Certified Insurance Fraud Analyst (CIFA), Certified Insurance Fraud Representative.
- EXPERIENCE: Minimum of 5 years of experience (10 years for Senior-level) in Special Investigations Unit specializing in provider or health care fraud involving workers compensation claims, or in law enforcement, or combination thereof, required.
- COMPUTER SKILLS: Must demonstrate strong technical competencies in the use of computers, standard business applications, Microsoft Office/365 applications, and Power BI and be able to master and become proficient in proprietary and vendor software programs.
LANGUAGE AND REASONING SKILLS
- Able to read and comprehend medical reports, medical billing, investigative reports, public records (e.g., licensing, ownership, etc.), claim file notes and attachments, legal documents, state-specific laws and regulations, moderately complex instructions, and business correspondence.
- Able to clearly and effectively draft detailed investigative reports, fraud referrals, and business correspondence.
- Able to effectively communicate with a wide range of internal and external parties.
- Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
- Able to solve practical problems involving several concrete variables in situations with limited standardization.
TRAVEL - Occasional travel one or more of the following required:
- Corporate Offices
- Offsite Meetings, Conferences and Industry Events
- Law Enforcement Agencies
- Provider Facilities
- Potential Witnesses (Field)
- Vendor Sites
WHAT WE OFFER
- Work-Life Balance
- Work From Home Program (up to 2 days per week upon eligibility)
- Modern Office Setting
- Free Garage Parking
- Fitness Facility Onsite
- Paid Time Off
- Paid Holidays
- Retirements Savings Match
- Group Health Insurance (Medical, Dental, and Vision)
- Life and AD&D Insurance
- Long Term Disability Insurance
- Accident and Critical Illness Insurance
- Flexible Savings Accounts
- Paid Community Volunteer Day
- Employee Assistance Program
- Tuition Reimbursement Program
- Employee Referral Program
- Diversity, Equity and Inclusion Program
$86,490 - $141,910 a year
This pay scale is an estimate of the salary range the employer reasonably expects to pay for the position based on potential employee qualifications, operational needs and other considerations consistent with applicable law. The actual salary may be above or below the range. The pay scale applies only to this position and only if it is filled in San Diego, California. The pay scale may be different for other positions or in other locations.
ABOUT US
With more than 50 years in business, BHHC has grown from a regional organization to a national insurance group, offering insurance products from coast to coast. Relationships are the cornerstone of our culture, and we believe in doing the right thing. That means we invest in our business in every way possible to deliver on our mission and demonstrate that people are what powers our success. Our commitment to financial strength and integrity means our customers can rest assured that we will be there when it counts.
At BHHC we embrace diversity and foster an environment where our people can be their authentic selves. Our differences make us stronger and better together, which fosters a harmonious workplace—something we truly value. We’ve created an approachable and collaborative atmosphere. Here you’ll find a welcoming workplace where everyone can feel valued, supported, and inspired to do great work. Together, we raise the bar by being curious, remaining customer-focused, and operating with integrity.
